FY2011 Health Benefits Booklet

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18 s u m m a r y o f g e n e r a l b e n e f i t s j u l y 2 0 1 0 – j u n e 2 0 1 1 Medical Benefits (includes routine vision and mental health coverage) Your Choices You have eight medical plans from which to choose: a• Preferred Provider Organization (PPO) Plans: • CareFirst BlueCross BlueShield; and • UnitedHealthcare; a• Point-of-Service (POS) Plans: • Aetna; • CareFirst BlueCross BlueShield; and • UnitedHealthcare; a• Exclusive Provider Organization (EPO) Plans: • Aetna; • CareFirst BlueCross BlueShield; and • UnitedHealthcare. In general, all options under each type of plan (PPO, POS, or EPO) cover the same services. However, the participating provider networks for the plans are different. Be sure to carefully review what’s covered by each type of plan, as well as which providers and facilities participate with the various plan networks. How the Plans Work Once you enroll in a medical plan, you will receive identification cards in the mail. Take these cards with you every time you receive medical services. Depending on what type of medical plan you choose, the way you receive medical services and how much you pay at the time of service will vary. Please review the plans carefully and select the plan that best suits your needs. PPO and POS plans offer out-of-network benefits. EPO plans do not provide out of network benefits except for true emergencies Please refer to the benefit charts on pages 19-32 for more details on each medical plan option. Allowed Amount The plan’s allowed amount refers to the reimbursement amount that the plan has contractually negotiated with network providers to accept as payment in full. Non-participating providers (out-of-network) are not obligated to accept the allowed amount as payment in full and may charge more than the plan’s allowed amount. In the charts that follow, if it indicates 80%, it means the plan pays 80% of the allowed amount. You are responsible for any amount above the plan’s allowed amount when you receive services from nonparticipating providers. Standard Benefits for Medical Plans The following charts are a summary of generally available benefits and does not guarantee coverage. To ensure coverage under any plan, contact that plan before obtaining any services or treatment. Call the plan for more information on coverage, limitations, exclusions, determinations of medical necessity, and preauthorization requirements. In addition, you will receive a description of coverage book from the plan in which you enroll that will provide details on your plan coverage. If Your Provider Terminates from Your Plan Network Providers may decide to terminate from a plan network at any time. If your provider terminates from your plan, please note it is not considered a qualifying event that would allow you to cancel or change your plan election. You will be able to change your plan election during the next Open Enrollment. NOTE: Outpatient prescription drug benefits are not included under the medical benefits plan and require a separate enrollment election. Please refer to page 37 for details. • There are no pre-existing condition limitations for any of the medical plans, but there are other exclusions. Please contact the medical plans for further information on coverage exclusions, limitations, determination of medical necessity, preauthorization requirements, etc. • For a list of plan providers, please access carrier websites located on the inside cover of this guide.
Maryland State Employees and Retirees 19 AETNA Benefit Pos In-Network Pos Out-of-Network EPO In-Network Only Plan Year Deductibles Individual Family None None $250 $500 None None Out-of-Pocket Coinsurance Maximums Individual Family None None $3,000 $6,000 None None Any fees above the plan’s Allowed Amount are not counted toward the out-of-pocket maximum. Lifetime Maximums $2 million per lifetime per person Unlimited National Network Yes Yes Yes Primary Care Physician No No Yes Referrals Required No No No AETNA HOSPITAL – INPATIENT SERvICES Inpatient Care (requires precertification) 100% of allowed benefit when precertified by Plan 80% of allowed benefit after deductible 100% of allowed benefit when precertified by Plan Inpatient care primarily for or solely for rehabilitation is not covered. Hospitalization 100% of allowed benefit when precertified by Plan 80% of allowed benefit after deductible 100% of allowed benefit when precertified by Plan Anesthesia 100% of allowed benefit when precertified by Plan 80% of allowed benefit after deductible 100% of allowed benefit when precertified by Plan Surgery (requires precertification) 100% of allowed benefit when precertified by Plan 80% of allowed benefit after deductible 100% of allowed benefit when precertified by Plan Organ Transplants (requires precertification) Per calendar year for cornea, kidney, and bone marrow Per 365 days up to $1 million per heart, heart-lung, single or double lung, liver, and pancreas 100% of allowed benefit when precertified by Plan 100% of allowed benefit when precertified by Plan 80% of allowed benefit after deductible 80% of allowed benefit after deductible 100% of allowed benefit when precertified by Plan 100% of allowed benefit when precertified by Plan AETNA HOSPITAL – ouTPATIENT SERvICES Chemotherapy/ Radiation 100% of allowed benefit 80% of allowed benefit after deductible 100% of allowed benefit Diagnostic Lab & X-Ray 100% of allowed benefit 80% of allowed benefit after deductible 100% of allowed benefit Outpatient Surgery (requires precertification) 100% of allowed benefit when precertified by Plan 80% of allowed benefit after deductible Anesthesia 100% of allowed benefit 80% of allowed benefit after deductible 100% of allowed benefit when precertified by Plan 100% of allowed benefit MEDICAL BENEFITS AETNA Benefit chart footnotes are on page 33
Page 1 and 2: State of Maryland July 2010 - June
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DEPARTMENT OF BUDGET & MANAGEMENT 3
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FY2011 Health Benefits Booklet

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